MINDFULNESS IN HEALTHCARE PROFESSIONALS AND MEDICAL EDUCATION
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
REVIEW PAPER
International Journal of Occupational Medicine and Environmental Health 2021;34(1):1 – 14
https://doi.org/10.13075/ijomeh.1896.01542
MINDFULNESS IN HEALTHCARE PROFESSIONALS
AND MEDICAL EDUCATION
JACEK CHMIELEWSKI1, KACPER ŁOŚ2, and WŁODZIMIERZ ŁUCZYŃSKI3
Medical University of Białystok, Białystok, Poland
1
Department of Psychiatry
2
Students’ Scientific Section at the Department of Medical Simulations
3
Department of Medical Simulations
Abstract
Healthcare professionals are exposed not only to the ubiquitous stress, but also to the culture of perfectionism. Therefore, they need tools to achieve
a balance between work and rest in order to effectively help their patients. The study objective is a review of the literature on the implementation
of mindfulness in healthcare professionals and medical students. The authors searched the literature in PubMed and Google Scholar databases
for publications about “mindfulness” in “healthcare professionals” and “medical students.” The search included manuscripts published to July 31,
2019. Mindfulness is a process of intentional paying attention to experiencing the present moment with curiosity, openness and acceptance of each
experience without judgment. Mindfulness training leads to a better mood perception, lower stress perception, and responding to stimuli more ef-
fectively. All these features can have a potentially positive effect on healthcare service. The paper describes methods of intervention as well as their
effects, which may be useful both in maintaining the well-being of healthcare professionals and in patient care. Mindfulness meditation has a ben-
eficial effect on stress, depression, burnout, well-being and empathy among doctors, nurses and other healthcare workers. However, the method has
a number of limitations, including a small number of participants, a high dropout rate in the intervention group and, above all, ceasing to practice
mindfulness in the longer term after the course termination. Mindfulness can be widely implemented by healthcare professionals, thus improving
their well-being and the quality of care they provide. Further standard scientific research is needed to confirm this impact. Int J Occup Med Environ
Health. 2021;34(1):1 – 14
Key words:
mindfulness, medical education, healthcare, medical students, nurses, doctors
INTRODUCTION certainly many reasons standing behind: some are due to
Healthcare professionals, on the one hand, face a number the lack of a proper work structure and education, others
of stressors in the medical environment, including those involve the shortage of human resources and materials,
always existing in medicine (long work hours, night shifts, as well as insufficient remuneration; high patient demand
pain and suffering of patients, caring for patients with life- also exerts an impact. Constant stress experienced by
threatening diseases, etc.) and the ones that have emerged healthcare professionals can lead to burnout syndrome,
recently (staffing shortages, increased numbers of complex attrition, depression and aggressive behaviors [1,2]. They
patients, diverse forms of healthcare financing, dynamic show a very high level of emotional exhaustion and deper-
changes in technology and regulations, etc.). There are sonalization [3]. Burnout syndrome and reduced quality of
Funding: this study was supported by the Medical University of Bialystok, Poland (grant No. N/ST/ZB/18/001/1206 entitled “Mindfulness and executive functions
in medical students during high-fidelity simulations,” chief investigator: Włodzimierz Łuczyński).
Received: September 14, 2019. Accepted: July 27, 2020.
Corresponding author: Włodzimierz Łuczyński, Medical University of Białystok, Department of Medical Simulations, Szpitalna 30, 15-029 Białystok, Poland (e-mail:
wlodzimierz.luczynski@umb.edu.pl).
Nofer Institute of Occupational Medicine, Łódź, Poland 1REVIEW PAPER J. CHMIELEWSKI ET AL.
life among doctors and nurses undoubtedly have a nega- cupational burnout, and eventually provide better health-
tive impact on well-being, performance and patient care. care service to the society.
The mechanisms of the above correlations have not been Thus, healthcare workers are not only exposed to the per-
fully elucidated yet. vasive stress associated with the amount of work, study
On the other hand, the modern work environment of and activity, but also to the culture of perfectionism that
physicians rewards efficiency, speed and productivity surrounds them all. They need tools to take a step back,
both among general practitioners (GPs) and specialists. see their actions from perspective, achieve a balance
These requirements force, in part, overlearned and au- between work, study and rest, and set priorities to both
tomatic actions in response to frequently recurring cases, maintain mental health and well-being, and deliver effec-
symptoms and medical conditions. However, these au- tive healthcare.
tomatisms can be dangerously mindless, leading to ste-
reotypies, monotony, inefficiency and a reduced quality of METHODS
the medical services provided. Similar mechanisms may The study objective is a narrative review of the literature
also apply to patients. In medical culture, too little atten- with support commentary on the implementation of mind-
tion has been paid to the well-being of medical students fulness in healthcare professionals and medical students.
and healthcare workers. Despite the growing awareness The authors aimed to include doctors, nurses and medi-
that self-care and self-awareness are key competences of cal students in a concise review, and add some personal
healthcare professionals, these issues seem to be largely experience in the field of medical education and mindful-
neglected in the process of medical education. Self-accep- ness meditation. They searched the literature in PubMed
tance is the foundation of any kind of care for another and Google Scholar databases for publications about
human being [4]. Since the features of mindfulness and “mindfulness” in “healthcare professionals” and “medi-
self-compassion should be considered to be at least par- cal students.” The search included manuscripts published
tially modifiable, more attention is required to shape to July 31, 2019. They described intervention methods and
them both in students and young as well as experienced their effects, which may be useful in maintaining the well-
doctors. being of healthcare professionals and in patient care. Lim-
For some time now, attempts have been made to prevent itations and difficulties in implementing mindfulness in
burnout syndrome through individual and systemic ap- healthcare service were also provided. Further directions
proaches. Both the limitation and organization of work, as for the development of research in this field of knowledge
well as mind/body training can bring benefits in this field. were proposed. They also added some personal experi-
General recommendations for doctors, nurses and stu- ence comments in the field.
dents on this issue have to be outlined [5]. The outcomes
of various types of interventions in this area are frequently RESULTS
inconsistent, and no research has been done on the impact Mindfulness as a stress reducing tool
of burnout in premedical students, or on suicide preven- Mindfulness is a process of intentionally paying attention
tion among doctors or nurses [6]. Further long-term, pro- to each moment with curiosity, openness and acceptance
spective and randomized studies are necessary. Perhaps of each experience without judgment [7]. This is achieved
interventions at a relatively low cost, both time-efficient through an attitude of acceptance, clarity, a lack of valu-
and collegial, will improve the quality of life, reduce oc- ation, patience, sincerity, unexpectedness, loving kind-
2 IJOMEH 2021;34(1)MINDFULNESS IN HEALTHCARE REVIEW PAPER
ness, care and compassion for the current situation. This that does not always produce a desired effect should be
experience allows switching from the normal mode of an enriched with the awareness of the inhibitors and facili-
automatic reaction to a more careful response that may tators of rationality in decision making. Learning critical
lead to a better understanding of oneself and the sur- thinking, developing cognitive and affective biases, and
rounding world. The mindfulness technique helps avoid using such processes as reflection and mindfulness can
the “autopilot” effect that may eventually cause unwanted lead to greater creativity, lateral thinking, and innovation
rumination, i.e., repeated negative looping thoughts about in the diagnosis and treatment of patients [12]. Scientific
oneself in the past and future. Mindfulness features cor- research in this field focuses both on the relationship of
relates with lower levels of stress, depression and anxiety, mindfulness traits with the quality of life of physicians and
while mindfulness training leads to a better mood percep- their approach to patients, as well as on possible changes
tion, the implementation of coping strategies for stress, in this area. Research accomplished as an intervention can
the ability to perceive a given situation more clearly, and be of quantitative or qualitative nature, and is carried out
responding to stimuli more effectively [8]. All these fea- as short- or long-term observations. Their results are gen-
tures can have a potentially positive effect on workplace erally consistent, but often differ in details. There are very
functioning in healthcare and medical education. few randomized and long-term studies in this field.
Implementing mindfulness in medicine and psychotherapy In the observation of 12 young doctors (average age:
has accelerated considerably in recent years. In the USA, 27.6 years), the features of mindfulness and self-compas-
mindfulness training is used in >250 medical centers. sion correlated positively with providing calm, compas-
The classic Mindfulness-Based Stress Reduction (MBSR) sionate care, resilience and clinician’s mental health [13].
program in adults who struggle with stress and its health In contrast, chronic stress showed a strong inverse corre-
consequences yields some improvement in well-being, as lation with these characteristics. This proves that mind-
well as reduces stress and its symptoms [9]. The loving fulness and self-compassion deeply affect the traits that
kindness meditation, which involves developing uncondi- medical educators seek in their students and future doc-
tional kindness to everyone, is a major mindfulness com- tors: clinician’s well-being and confidence in providing
ponent [10]. This skill can be extremely useful in work with calm, compassionate care. According to the authors of
patients and in medical team work. that report, it remains to determine which type of training
All the features of stress management described above can most effectively improves mindfulness and self-compas-
be implemented in medical and nursing practice. It can be sion among physicians. The limitation of this observation
assumed that support based on cognitive, behavioral and was not only a small number of participants, but also vol-
mindfulness approaches will help reduce stress of doctors, untary self-enrollment in the elective meditation-focused
nurses and medical students, ease anxiety and the feeling seminar.
of burnout, and improve patient care [11]. In turn, mind-body medicine (MBM) facilitators from
the Georgetown University School of Medicine were char-
Medical staff acterized by lower levels of stress (assessed according to
Doctors the Perceived Stress Scale) and a higher level of mindfulness
Mindfulness can become the missing link between evi- (according to the Freiburg Mindfulness Inventory) in com-
dence-based medicine and relationship-centered care. parison with normative controls [14]. These effects were
Perhaps the routine diagnostic and therapeutic process also shown on the hormonal level including salivary cortisol,
IJOMEH 2021;34(1) 3REVIEW PAPER J. CHMIELEWSKI ET AL.
dehydroepiandrosterone sulfate, testosterone and secretory This approach has its strengths and weaknesses. The major
immunoglobulin A [15]. With the above in mind, the Men- problems of this type of research is unwillingness to par-
toring and Professionalism in Training Program for pathol- ticipate in such programs, self-selection, motivation, etc.
ogy residents, in addition to other themes, takes mindful- Additionally, exam sessions or their completion during
ness into account as an important issue in the promotion or after the course may be a disruptive factor (stress and
of humanism in healthcare professionals in the health mood improvement or worsening regardless of the course
system [16]. being held). The lack of course continuation as part of
Conducting a full 8-week MBSR course for doctors the proposed post-course maintenance sessions is a major
working in a hospital or university seems to be a time- concern. Only 2 residents in the first 2 sessions took part in
consuming and expensive task. Therefore, simpler and the maintenance session in that study. Unfortunately, this
equally effective solutions are searched for. An interesting can be observed in all mindfulness-based courses. Very
experiment was carried out at the University of Wiscon- few people decide to enroll in the post-course sessions or
sin, in which leaders were prepared and trained to pro- come to the subsequent group meetings (the authors’ own
mote the mindfulness concept among healthcare provid- experience based on work with MBSR groups). The con-
ers [17]. The effects exceeded the initiators’ expectations tinuation of the mindfulness practice is one of the major
and the investment that had been made. Five leaders from issues and challenges in this field, especially in extremely
primary care departments not only appreciated the value busy healthcare professionals.
of mindfulness but, above all, fostered mindfulness ac- Another idea to achieve an effect using smaller resources
tivities among their colleagues, students and patients in is to shorten the full MBSR course. In an uncontrolled
the state of Wisconsin and beyond. Indeed, it appears to pilot study, GPs were subjected to the abbreviated version
be an excellent idea to spread the concept of mindfulness of MBSR [3] and, as a result, the features of burnout, de-
in the medical world at little expense. Obviously, this type pression, anxiety and stress were found to be reduced both
of a project has its limitations, including the sample size, immediately after the intervention and 9 months later. In-
the lack of statistical analysis, the lack of measurements terestingly, also in this case, no changes were observed in
before and after the intervention, and no randomization. resilience and compassion. Satisfactory attempts were also
In a similar program conducted by a colleague experi made to reduce the costs of the MBSR program by replac-
enced in mindfulness training, pediatric residents expe ing 6 out of 8 traditional personal meetings by telephone
rienced improvements in their positive attitude, perceived group sessions (tMBSR) [19]. The impact of the course
stress and resilience after mind-body skills training even was greater in people who continued their mindfulness
though they completed, on average, 4.3 out of 8 online practice after completing the course as compared to those
modules, and 2.8 of 4 personal sessions [18]. The long- who did not. This indicates that the program can be im-
term effects (after 6 months) in that study included a re- plemented in groups of healthcare professionals who are
duction in the symptoms of burnout and an increase in not available in a traditional, personal way (on-site pro-
mindfulness. The course participants indicated that the fa- grams).
cilitator helped them introduce new skills to the residents’ In one of the first randomized trials, MBSR was used
lives. However, no changes were noted in the field of self- among 148 residents of medicine, surgery and primary
compassion. Perhaps this was due to the lack of formal, care [20]. In the whole group, 3 months after the baseline
standardized education of the course leader. assessment, no significant differences were noted between
4 IJOMEH 2021;34(1)MINDFULNESS IN HEALTHCARE REVIEW PAPER
the group subjected to mindfulness and the wait-list control ceptance at work, and – importantly for their profession-
group in terms of emotional exhaustion. However, greater alism and patient care – acceptance for their own limita-
improvements were observed after MBSR with regard to tions [26]. Moreover, they mentioned being more resil-
personal accomplishment, worry, mindfulness skills, self- ient, and better at setting priorities and limits. In addition,
compassion and perspective-taking. In the further analysis the residents asked for help more often and seemed to be
of this material, it was pointed out that persons with great- more open towards feedback. Importantly, they indicated
er baseline emotional exhaustion did seem to benefit from an enhanced sense of compassion for others. Physicians
the MBSR course. In another report, it was stated that who completed a 52-hour program focusing on mindful
stress reduction after MBSR in healthcare professionals communication experienced its 3 aspects:
depended on the reduction in rumination and negative – sharing experiences from medical practice reduced
affect [21]. This effect was maintained throughout the ob- the sense of isolation;
servation period 3 months after the course. A study con- – mindfulness skills improved the ability to focus atten-
ducted in the Galveston University medical staff revealed tion and boosted attentive listening with adequate re-
that the effect of MBSR in terms of perceived stress and sponse;
well-being persisted and was stable over the year of a fol- – development of self-awareness was a positive experi-
low-up after the intervention [22]. In another observa- ence, although the participants did not always give
tion, primary care physicians participating in a full MBSR themselves permission to attend to their own develop-
course reported a significant decrease in depersonaliza- ment [27].
tion, and an increase in dedication and mindfulness skills. A very interesting observation was made when searching
Changes in empathy were not observed [23]. for the relationship between mindfulness, the quality of
Few data are available on the impact of mindfulness on life and the quality of patient care (from the doctor’s per-
the representatives of particular medical specialties. spective) among American oncologists [28]. In this group
In a very small group of psychiatry residents (11 people), of doctors, mindfulness influenced life satisfaction and
empathy increased, and perceived stress decreased, after a less suboptimal patient care. Mindfulness moderated
a mindfulness course, although this last change was not the relationship between the oncologists’ sleep problems
statistically significant [24]. and suboptimal patient care. It is likely that the skills ac-
It is extremely difficult to check whether mindfulness af- quired during mindfulness courses will be passed on to
fects the quality of patient care, as it requires random- patients, especially those with chronic, psychosomatic or
ized, long-term clinical trials. The mindfulness course life-threatening diseases. Undoubtedly, the above data
specially designed for healthcare professionals resulted in show a positive effect of mindfulness on the mental health
stress, anxiety and burnout reduction [25]. As a qualita- of doctors.
tive effect, a positive impact was reported on the quality
of patient care and on planning to use this technique both Nurses
in personal development and in work with patients. Both Mindfulness meditation has a beneficial effect on stress,
teaching and assessing the professionalism of young doc- anxiety, depression, burnout, well-being and empathy
tors and residents appear a great challenge. The MBSR among nurses. However, most reports refer to a small
courses may be helpful – after completing them, residents number of respondents and a short observation time, thus
admitted increased awareness, self-reflection and self-ac- limiting the generalization of results. In 13 Brazilian hos-
IJOMEH 2021;34(1) 5REVIEW PAPER J. CHMIELEWSKI ET AL.
pital nurses, a 6-week Stress Reduction Program (based plan to use this technique for themselves and in work with
on MBSR by Kabat-Zinn), with elements of mindfulness the patient. Summing up, mindfulness meditation eases
and loving kindness meditation, reduced the symptoms work-related stress among nurses.
of stress, burnout, depression and anxiety (as a trait),
with the effects sustained throughout a long-term follow- Medical students
up [29]. The course participants admitted experiencing Medical universities are constantly raising the level of ed-
such feelings as: a more attentive perception of internal ucation and requirements for both prospective undergrad-
and external experience, a greater attention and aware- uate students and graduates. Standardized examinations
ness of actions and attitudes at every moment, and finally and new subjects are introduced, and the number of learn-
a positive influence on nursing activities. The limitations of ing hours increases. It may thus seem that the level of pro-
the study included a small number of subjects, no control fessionalism among young doctors is also higher. Para-
group and no randomization. The strength of the study doxically, however, students report being overloaded with
was certainly a positive effect persisting after the end of activities, and burdened with constant stress and a sense
the course. of competition. According to some research, medical
The latest study, being one of the first fully randomized, students also show low emotional and cognitive empathy
standardized studies in this field, investigated the impact scores, and an avoidant attachment style [35]. This may
of an 8-week classic MBSR course on 110 nurses work- increase burnout and decrease the ability to connect with
ing in general hospitals [30]. After the intervention, stress patients [36].
and negative affect decreased, whereas positive affect Despite the awareness that medical studies are very stress-
and resilience increased. As for job satisfaction, the posi- ful, and that stress has an impact on mental and physi-
tive trend did not reach statistical significance. Among cal health, no effective methods have been established
the challenges of the MBSR programs for nurses, restless- to combine intensive learning, interest in research, and
ness, physical pain and dealing with difficult emotions are the ability to take self-care and improve mentally. Older
mentioned [31]. Some positive effects of the mindfulness physicians begin to be interested in building relationships
course, such as an increase in individual and workplace with patients, which they enjoy. However, this type of an
resilience, were also observed among midwives [32]. attitude could be adopted by students during their medi-
In a study covering a broad spectrum of healthcare pro- cal education, yet it requires a change in thinking and in
viders, including nurses, doctors, psychologists and social the approach to studying medicine, along with a conscious
workers, a positive impact on emotional exhaustion, de- willingness to build a relationship with the patient and to
personalization and personal accomplishment was dem- learn how to do it. This path may lead to the concept of
onstrated [33]. Various groups of healthcare professionals relationship-centered care, self-awareness and mindful-
are interested in mindfulness courses: nurses, physicians, ness as the basis of medical education.
social workers, dietitians, psychologists and others [34]. Medical universities, apart from accreditation organiza-
The most popular topics that healthcare workers would tions, should develop programs to support mental health
like to explore are “Introduction to stress, resilience and re- and well-being of their graduates. Healthcare profession-
laxation response” and “Autogenic training.” Half of those als are co-responsible for the health and well-being of
willing to participate usually complete at least 1 module, those they serve. Therefore, strategies are needed to help
but only 9% take part in all 12 modules. Nearly all (90%) both students and workers to maintain resilience and well-
6 IJOMEH 2021;34(1)MINDFULNESS IN HEALTHCARE REVIEW PAPER
being in their professional and personal lives so that they conducted at Boston University, the Embodied Health
could provide service to the best of their knowledge and Elective was carried out combining yoga, mindfulness
skills for as long as possible. Such strategies are already techniques and educational elements oriented towards
being introduced, mostly in a pilot or facultative form, but scientific research into mind-body practices, in a group
not only. Examples include programs implemented in U.S. of 27 first- and second-year medical students [42]. As a re
universities, such as Resilience and Well-being for Health sult, a significant increase was observed in self-regulation
Professionals, Mind-Body Medicine Skills, and Mindful and self-compassion. In addition, there was an improve-
Resilience [37]. Their long-term follow-up outcome will ment tendency in terms of empathy and perceived stress,
be crucial. but these effects did not reach statistical significance.
Self-awareness and reflection have long been promoted According to the participating students, these changes
through mind-body skills among medical students [38]. were caused by:
However, the study results are still insufficient, do not – reconnection between the body and mind,
refer to larger sample groups, do not assess long-term ef- – community in a competitive environment,
fects, and do not investigate the relationship with learn- – increased mindfulness,
ing and further work as a doctor. Perhaps mindfulness will – confidence in the use of mind-body skills with patients,
extend the teacher-student relationship for the benefit of – stress management.
both, and emphasize the healer’s role in medicine [39]. The limitations of the study were: no control group, self-
Undoubtedly, being a good clinical teacher and being enrollment in the study, a small number of students,
a mindful teacher share many characteristics. a short observation time, and a fairly high empathy score
Such mindfulness effects as enhanced empathy, reduced at baseline, suggesting a ceiling effect for this measure.
anxiety and stress, and increased self-regulation (the abil- Similarly, MBSR reduced tension, anxiety and total mood
ity to effectively manage one’s thoughts and actions to disturbance in second-year medical students as compared
complete a task) can be particularly useful for medical stu- to those who participated in seminars on complementary
dents who struggle with heavy workload, have to memo- medicine [43]. A similar course based on meditation re-
rize a lot of information in a short time, and are constantly duced stress and increased empathy in premedical and
subjected to tests. Mindfulness courses can lead to a great- medical students [44]. Students of medicine and psychol-
er sense and resilience among medical students, an ability ogy experienced a change towards reduced reactivity,
to manage their workflow better, and more acceptance of increased curiosity, affect tolerance, patience and self-
their limitations as learners [40]. A meta-analysis of 19 stu- acceptance, and improved relational qualities [45]. Cer-
dies concerning the use of mindfulness among medical tainly, mindfulness meditation reduces the level of cortisol
students has shown that mindfulness-based interventions in the serum of medical students [46].
decrease stress, anxiety and depression, as well as im- Stress and depression have a negative impact on empathy.
prove mindfulness, mood, self-empathy and empathy [41]. Thus, mindfulness seems to be a good instrument to im-
As revealed by the authors of that analysis, mindfulness prove empathy and the quality of patient care. However,
training can be relatively easily adapted to and integrated not all studies seem to confirm the impact of mindful-
with the modern teaching of medicine. ness on reducing stress and improving empathy. For ex-
The vast majority of mindfulness classes are based on vol- ample, in a study conducted among first-year students of
untary student participation. In a very interesting study medicine, an increase in stress and a decrease in empathy
IJOMEH 2021;34(1) 7REVIEW PAPER J. CHMIELEWSKI ET AL.
were observed regardless of the MBM training. However, subjective well-being [53]. Thus, female students seem to
the completion of this course protected them from an be an important target group of mindfulness intervention.
increase in depression, which was observed in the group In another study, it was also shown that the medical stu-
without therapy [47]. Perhaps the observed stress was dents interested in mindfulness courses are characterized
caused by heavy workload and credits. In another study, by higher psychological distress, neuroticism, worrying,
nursing students after MBSR intervention showed an in- problem avoidance and lower mindfulness skills compared
crease in mindfulness, but no effect on stress or the quality to those unwilling to do the course [49].
of life was noted [48]. Interestingly, after graduating, the choice of residency in
The timing of such interventions seems to be crucial. the field of primary care practice among 208 osteopath-
An MBSR course carried out during the first year of med ic medical students was not related to mindfulness as-
ical studies showed a small-to-moderate influence on sessed using the Five Facet Mindfulness Questionnaire [54].
mental health and no impact on the students’ empathy in On the other hand, the students who chose emergency
a 20-month observation period [49]. In the authors’ sub- medicine as their future specialization and participated
jective opinion, the decisive factor may be experiencing in a mindfulness course during summer holiday clerkships
lower stress during clerkships as compared to full-time noted some changes in self-reported behaviors and atti-
studying with credits, tests and exams, as is the case among tudes that lasted for ≤6 months after intervention [55].
residents. In another study, it was clearly shown in a small Despite the small size of the group sample (20 students),
group of graduate healthcare students that statistically sig- this may indicate that burnout syndrome can be prevented
nificant effects of MBSR concerning burnout and empa- in future emergency medicine physicians.
thy can be brief if not sustained by regular practice [50]. In all the studies described above, students enrolled
Some studies have attempted to qualitatively describe themselves voluntarily in mindfulness programs during
the changes obtained through mindfulness intervention. their university education. In the only known study that
The students of medicine and nursing who underwent assessed the obligatory course of stress management and
the mind-body skills course identified 3 main topics of their resilience, introduced in the first year of medicine, no
interest in this aspect: “ability to be more present,” “in- positive intervention effect was observed as compared to
creased perception and awareness of oneself” and “con- the control cohort [56]. The mental quality of life, hap-
nection on a deeper level with others” [51]. All these fea- piness decline and stress scores were all statistically sig-
tures can be very useful in their future work with patients. nificantly increased in both cohorts during the observation
Gender differences may exist in the mindfulness recep- year. No differences were noted in burnout or resilience.
tion. In a study conducted after an MBSR course, an Perhaps people who voluntarily participate in mindfulness
improvement was noted only in female medical students courses are the ones who benefit the most from them.
in terms of mental distress, study stress, subjective well- Another limitation of this type of research may be the com-
being and mindfulness [52]. It might be due to the high parison of mindfulness interventions with the wait-list
attendance and performance of all recommended tasks by control group not receiving any support during the obser-
female students. Further research conducted in this group vation period. The German MediMind study compared
demonstrated that higher neuroticism and conscientious- the effect of mindfulness therapy with standard treatment
ness, more frequently found in female students, predis- (autogenic training) and a control group without inter-
pose them to better effects in terms of mental distress and vention [57]. No statistically significant positive effect of
8 IJOMEH 2021;34(1)MINDFULNESS IN HEALTHCARE REVIEW PAPER
mindfulness therapy on stress management among medi- participants was small and the course was completed by
cal students was observed due to, among other things, high almost everyone; however, in the subsequent 1–2 years,
dropout rates for the students who suffered from psycho- not more than several percent of those interested contin-
logical symptoms. However, the authors of that report ued their weekly practice (personal data, unpublished).
pointed out that the number of people willing to partici- In the authors’ opinion, maintaining the achieved attitude
pate was high (183 people), which indicates the need for in further personal and professional life will be critical.
further development of activities in this direction. Therefore, all the barriers that limit regular practice and
In the only known long-term follow-up (6 years) involv- meditation after mindfulness training have to be identi-
ing 288 Norwegian students of medicine and psychol- fied, and specific tools have to be used to remind the par-
ogy, positive effects were demonstrated in terms of well- ticipants of mindfulness practice. One can only assume
being, problem-focused coping and avoidance-focused that those who, thanks to mindfulness, can cope with
coping [58]. These effects were noted despite the relatively stress effectively will continue the practice. It should also
low levels of adherence to formal mindfulness practice, be taken into account that some students or healthcare
which suggests that mindfulness acts not as a state, but as workers are already at the adequate level of mindfulness.
a trait, and it indicates the importance of informal practic- As shown by the above research survey, a mindfulness
es in shaping mindfulness attitudes on a daily basis. Medi- course is easier to conduct among students than among
cal school students in Malaysia assessed that the mindful- doctors or nurses, as the former are more available than
ness-based stress management program (MBSM/Mindful- professionally active employees. However, the outcome of
Gym) could be useful in helping patients [59]. Mindfulness the research conducted on students cannot fully translate
not only reduces stress in medical students, but also helps into the real work of physicians, since the final effect in-
them look forward more confidently and hopefully to be- volves a great deal of additional factors, as well as profes-
coming physicians [60]. sional environment or family, etc., which determine the at-
tainment of mindfulness objectives in everyday work with
Mindfulness-related problems patients in hospital or outpatient settings. In addition, no
and development perspectives one will appreciate the impact of mindfulness on well-be-
The analysis of the current study stimulates a number of ing, communication with patients and effective work/rest
questions and raises doubts as to the application of mind- like the highly experienced healthcare workers. A higher
fulness in healthcare workers. Numerous authors have level of stress in medical students or doctors as compared
concluded that conducting an MBSR course is feasible to general population can be another factor influencing
among healthcare professionals and students. The criti- the effectiveness of mindfulness.
cal analysis of a great deal of studies seems to indicate Long-term, randomized studies assessing the impact of
that many circumstances interfere with the task. A small mindfulness on burnout and the quality of patient care
number of course participants, a high course withdrawal are constantly lacking. The lack of a control group is one
rate and, first of all, course discontinuation or neglecting of the major problems. Voluntary enrollment in the inter-
mindfulness practice in the longer term after the course vention hinders the outcome translation into the whole
termination, prove that, as stated by Kabat-Zinn [7], being healthcare population. Likewise, it is not known how
mindful in everyday life is simple but not easy. The au- the people who continue mindfulness practice differ from
thors of this article share this experience – the number of those who do not. Undoubtedly, such factors as the type
IJOMEH 2021;34(1) 9REVIEW PAPER J. CHMIELEWSKI ET AL.
of mindfulness practice, its organization mode, imple- doctor’s performance at work? Does anyone being more
mentation in everyday activities, duration, and optional or mindful respond better to stressful situations in medicine?
obligatory participation in the course will exert an impact Is anyone who escapes rumination and observes his/her
on the outcome. Being aware of the realities of work in own feelings more effective in emergency medicine ac-
medicine, the authors realize that it is almost impossible tions? Does mindfulness help in managing human teams
to conduct a randomized study with a long-term follow-up in life-threatening events? Do the features of mindfulness
in a large group. help make quick and proper diagnostic and therapeutic
There is a growing interest in the issue of the impact of decisions? Is mindfulness associated with technical or soft
mindfulness on teaching effects and effective learning, skills of students and doctors? Does being more mindful
which refers both to students and young as well as experi- result in more attentive listening to patients and the ac-
enced doctors. However, no research data are available. companying persons or members of the medical team?
The question arises whether the student’s condition before The authors tried to answer some of these questions by
university education has an effect on the development of conducting research assessing the relationship of the fea-
stress and its complications. Can doctors be taught to cope tures of mindfulness with technical and soft skills of medi-
not only with their own stress but also with their patients’ cal students during high-fidelity medical simulations [61].
stress? Mindfulness interventions aim to create a possi- Their unpublished preliminary experiments and analyses
bility for being more aware of one’s own experience, and seem to indicate that the mindfulness of a student who
for a better recognition of stressors, and regulations of is in charge of a medical team in life-threatening events
thoughts and feelings, in order to block harmful effects. (medical simulation) is associated with soft skills and
The objective of mindfulness is to allow healthcare work- stress perception by the simulation participant, but it does
ers to keep a distance from a mentally and emotionally not affect technical skills. These findings require further
stressful environment. The structure of medical universi- research and have to be confirmed in larger groups in stan-
ties should incorporate instruments and programs to ac- dardized conditions.
complish these objectives. The questions that still remain Thus, the ideal assessment of mindfulness in healthcare
open are as follows: when should mindfulness be taught professionals should:
on the path of a medical career? Which format is the best – be a randomized study,
and who should it address? How can long-term effects of – eliminate the impact of voluntary enrollment in the in-
mindfulness be maintained? Should mindfulness be in- tervention (if it is at all possible),
cluded in the university curriculum for medical students? – be based on a standardized course of mindfulness
Should mindfulness be taught as an elective or obligatory (e.g., an 8-week MBSR course),
subject? It would be interesting to check when the inter- – be a long-term assessment,
ventions are optimal – at the beginning or end of the study, – evaluate the effects for the student/doctor/nurse’s well-
at the start or finish of the residency period? being,
Research into whether mindfulness traits influence diag- – evaluate the effects in theoretical and practical exams
nostic and therapeutic decisions in life-threatening condi- (if the impact on learning/training is examined),
tions can be extremely interesting. There are more ques- – assess the impact of mindfulness on team work,
tions than answers in this field, and no studies are avail- – assess the effects at work with patients (if possible),
able. Does being here and now result in a better or worse – evaluate both quantitative and qualitative effects.
10 IJOMEH 2021;34(1)MINDFULNESS IN HEALTHCARE REVIEW PAPER
CONCLUSIONS 5. Ripp JA, Privitera MR, West CP, Leiter R, Logio L, Sha-
In conclusion, the implementation of the well-being en- piro J, et al. Well-Being in Graduate Medical Education:
hancing techniques in healthcare professionals and medi- A Call for Action. Acad Med. 2017;92(7):914–7, https://doi.
cal education should be recommended for the benefit of org/10.1097/ACM.0000000000001735.
both patients and medical service providers. The mindful 6. Williams D, Tricomi G, Gupta J, Janise A. Efficacy of burnout
perspective may have an impact on therapeutic decisions interventions in the medical education pipeline. Acad Psychiatry.
and cooperation with patients, leading to better health 2015;39(1):47–54, https://doi.org/10.1007/s40596-014-0197-5.
effects. The analysis of the above data seems to suggest 7. Kabat-Zinn J. Mindfulness-Based Interventions in Con-
that enhanced self-awareness in healthcare professionals text: Past, Present, and Future. Clin Psychol: Sci Pract.
and medical students will allow them to more frequently 2003;10(2):144–56, https://doi.org/10.1093/clipsy.bpg016.
engage in self-care activities and to manage stress more 8. Shapiro SL, Carlson LE, Astin JA, Freedman B. Mechanisms
effectively. They can be also better equipped with instru- of mindfulness. Clin Psychol. 2006;62(3):373–86, https://doi.
ments improving wellness in their patients. Mindfulness org/10.1002/jclp.20237.
can be widely applied in healthcare professionals, boost- 9. Carmody J, Baer RA. Relationships between mindfulness
ing their well-being and improving the quality of care pro- practice and levels of mindfulness, medical and psychologi-
vided. However, further research conducted according to cal symptoms and well-being in a mindfulness-based stress
scientific standards is needed to confirm this correlation. reduction program. J Behav Med. 2008;31(1):23–33, https://
doi.org/10.1007/s10865-007-9130-7.
REFERENCES 10. Hofmann SG, Grossman P, Hinton DE. Loving-kindness
1. Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, and compassion meditation: potential for psychological in-
et al. Burnout and satisfaction with work-life balance among terventions. Clin Psychol Rev. 2011;31(7):1126–32, https://
US physicians relative to the general US population. Arch doi.org/10.1016/j.cpr.2011.07.003.
Intern Med. 2012;172(18):1377–85, https://doi.org/10.1001/ 11. Regehr C, Glancy D, Pitts A, LeBlanc VR. Interventions to
archinternmed.2012.3199. reduce the consequences of stress in physicians: a review and
2. Botha E, Gwin T, Purpora C. The effectiveness of mindful- meta-analysis. J Nerv Ment Dis. 2014;202(5):353–9, https://
ness based programs in reducing stress experienced by nurses doi.org/10.1097/NMD.0000000000000130.
in adult hospital settings: a systematic review of quantitative 12. Croskerry P. Adaptive expertise in medical decision making.
evidence protocol. JBI Database System Rev Implement Rep. Med Teach. 2018;40(8):803–8, https://doi.org/10.1080/01421
2015;13(10):21–9, https://doi.org/10.11124/jbisrir-2015-2380. 59X.2018.1484898.
3. Fortney L, Luchterhand C, Zakletskaia L, Zgierska A, Ra 13. Olson K, Kemper KJ. Factors associated with well-being and
kel D. Abbreviated mindfulness intervention for job satisfac- confidence in providing compassionate care. J Evid Based
tion, quality of life, and compassion in primary care clinicians: Complementary Altern Med. 2014;19(4):292–6, https://doi.
a pilot study. Ann Fam Med. 2013;11(5):412–20, https://doi. org/10.1177/2156587214539977.
org/10.1370/afm.1511. 14. Talisman N, Harazduk N, Rush C, Graves K, Haramati A.
4. Schmidt S. Mindfulness and healing intention: concepts, prac- The impact of mind-body medicine facilitation on affirming
tice, and research evaluation. J Altern Complement Med. and enhancing professional identity in health care profes-
2004;10 Suppl 1:s7–14, https://doi.org/10.1089/1075553042 sions faculty. Acad Med. 2015;90(6):780–4, https://doi.org/
245917. 10.1097/ACM.0000000000000720.
IJOMEH 2021;34(1) 11REVIEW PAPER J. CHMIELEWSKI ET AL.
15. Maclaughlin BW, Wang D, Noone AM, Liu N, Harazduk N, reduction for GPs: results of a controlled mixed methods
Lumpkin M, et al. Stress biomarkers in medical students pilot study in Dutch primary care. Br J Gen Pract. 2016;
participating in a mind body medicine skills program. Evid 66(643):e99–105, https://doi.org/10.3399/bjgp16X683497.
Based Complement Alternat Med. 2011;2011:950461, https:// 24. Hoenders HJ, Booij SH, Knegtering H, van den Brink H.
doi.org/10.1093/ecam/neq039. [Mindfulness training for psychiatrists in residency: a pilot
16. Esposito MJ, Roychoudhury S, Fornari A. A Professional- study]. Tijdschr Psychiatr. 2016;58(11):809–13. Dutch.
ism and Mentoring Curriculum for Pathology Residents in 25. Kinser P, Braun S, Deeb G, Carrico C, Dow A. “Awareness
Training. Acad Pathol. 2018;5:2374289518805062, https:// is the first step”: An interprofessional course on mindfulness
doi.org/10.1177/2374289518805062. and mindful-movement for healthcare professionals and stu-
17. Luchterhand C, Rakel D, Haq C, Grant L, Byars-Winston A, dents. Complement Ther Clin Pract. 2016;25:18–25, https://
Tyska S, et al. Creating a Culture of Mindfulness in Medi- doi.org/10.1016/j.ctcp.2016.08.003.
cine. WMJ. 2015;114(3):105–9. 26. Verweij H, van Ravesteijn H, van Hooff MLM, Lagro-Jans-
18. Romcevich LE, Reed S, Flowers SR, Kemper KJ, Mahan JD. sen ALM, Speckens AEM. Does Mindfulness Training En-
Mind-Body Skills Training for Resident Wellness: A Pilot hance the Professional Development of Residents? A Quali-
Study of a Brief Mindfulness Intervention. J Med Educ Cur- tative Study. Acad Med. 2018;93(9):1335–40, https://doi.
ric Dev. 2018;5:2382120518773061, https://doi.org/10.1177/ org/10.1097/ACM.0000000000002260.
2382120518773061. 27. Beckman HB, Wendland M, Mooney C, Krasner MS,
19. Bazarko D, Cate RA, Azocar F, Kreitzer MJ. The Impact of Quill TE, Suchman AL, et al. The impact of a program in mind-
an Innovative Mindfulness-Based Stress Reduction Program ful communication on primary care physicians. Acad Med.
on the Health and Well-Being of Nurses Employed in a Cor- 2012;87(6):815–9, https://doi.org/10.1097/ACM.0b013e3182
porate Setting. J Workplace Behav Health. 2013;28(2):107– 53d3b2.
33, https://doi.org/10.1080/15555240.2013.779518. 28. Kracen A. Mindfulness, health, well-being, and patient care
20. Verweij H, van Ravesteijn H, van Hooff MLM, Lagro- of oncologists. Richmond, Virginia: Virginia Commonwealth
Janssen ALM, Speckens AEM. Mindfulness-Based Stress University; 2009.
Reduction for Residents: A Randomized Controlled Trial. 29. Dos Santos TM, Kozasa EH, Carmagnani IS, Tanaka LH,
J Gen Intern Med. 2018;33(4):429–36, https://doi.org/10.1007/ Lacerda SS, Nogueira-Martins LA. Positive Effects of a Stress
s11606-017-4249-x. Reduction Program Based on Mindfulness Meditation in
21. Martín-Asuero A, García-Banda G. The Mindfulness-based Brazilian Nursing Professionals: Qualitative and Quantitative
Stress Reduction program (MBSR) reduces stress-related Evaluation. Explore (NY). 2016;12(2):90–9, https://doi.org/
psychological distress in healthcare professionals. Span 10.1016/j.explore.2015.12.005.
J Psychol. 2010;13(2):897–905, https://doi.org/10.1017/s113874 30. Lin L, He G, Yan J, Gu C, Xie J. The Effects of a Modified
1600002547. Mindfulness-Based Stress Reduction Program for Nurses:
22. Geary C, Rosenthal SL. Sustained impact of MBSR on stress, A Randomized Controlled Trial. Workplace Health Saf.
well-being, and daily spiritual experiences for 1 year in aca- 2018;2165079918801633, https://doi.org/10.1177/216507991
demic health care employees. J Altern Complement Med. 8801633.
2011;17(10):939–44, https://doi.org/10.1089/acm.2010.0335. 31. Cohen-Katz J, Wiley S, Capuano T, Baker DM, Deitrick L,
23. Verweij H, Waumans RC, Smeijers D, Lucassen PL, Don Shapiro S. The effects of mindfulness-based stress reduction
ders AR, van der Horst HE, et al. Mindfulness-based stress on nurse stress and burnout: a qualitative and quantitative
12 IJOMEH 2021;34(1)MINDFULNESS IN HEALTHCARE REVIEW PAPER
study, part III. Holist Nurs Pract. 2005;19(2):78–86, https:// coping, reserve and professional development. Edu Res Int.
doi.org/10.1097/00004650-200503000-00009. 2019;2019:4021729, https://doi.org/10.1155/2019/4021729.
32. Foureur M, Besley K, Burton G, Yu N, Crisp J. Enhancing 41. McConville J, McAleer R, Hahne A. Mindfulness Training
the resilience of nurses and midwives: pilot of a mindful- for Health Profession Students-The Effect of Mindfulness
ness-based program for increased health, sense of coher- Training on Psychological Well-Being, Learning and Clini-
ence and decreased depression, anxiety and stress. Con- cal Performance of Health Professional Students: A Sys-
temp Nurse. 2013;45(1):114–25, https://doi.org/10.5172/conu. tematic Review of Randomized and Non-randomized Con-
2013.45.1.114. trolled Trials. Explore (NY). 2017;13(1):26–45, https://doi.
33. Goodman MJ, Schorling JB. A mindfulness course decreas- org/10.1016/j.explore.2016.10.002.
es burnout and improves well-being among healthcare pro- 42. Bond AR, Mason HF, Lemaster CM, Shaw SE, Mullin CS,
viders. Int J Psychiatry Med. 2012;43(2):119–28, https://doi. Holick EA, et al. Embodied health: the effects of a mind-
org/10.2190/PM.43.2.b. body course for medical students. Med Educ Online.
34. Gupta SJ, Kemper KJ, Lynn J. Interest in online interprofes- 2013;18:1–8, https://doi.org/10.3402/meo.v18i0.20699.
sional elective mind-body skills (MBS) training. Complement 43. Rosenzweig S, Reibel DK, Greeson JM, Brainard GC,
Ther Med. 2018;36:137–41, https://doi.org/10.1016/j.ctim. Hojat M. Mindfulness-based stress reduction lowers psy-
2017.12.009. chological distress in medical students. Teach Learn
35. Dehning S, Gasperi S, Krause D, Meyer S, Reiß E, Burger M, Med. 2003;15(2):88–92, https://doi.org/10.1207/S15328015TL
et al. Emotional and cognitive empathy in first-year medi- M1502_03.
cal students. ISRN Psychiatry. 2013;2013:801530, https:// 44. Shapiro SL, Schwartz GE, Bonner G. Effects of mind-
doi.org/10.1155/2013/801530. fulness-based stress reduction on medical and premedi-
36. Dyrbye LN, Thomas MR, Massie FS, Power DV, Eacker A, cal students. J Behav Med. 1998;21(6):581–99, https://doi.
Harper W, et al. Burnout and suicidal ideation among U.S. org/10.1023/a:1018700829825.
medical students. Ann Intern Med. 2008;149(5):334–41, 45. Solhaug I, Eriksen TE, de Vibe H, Haavind H, Friborg O,
https://doi.org/10.7326/0003-4819-149-5-200809020-00008. Sørlie T, et al. Medical and Psychology Student’s Experiences
37. Kreitzer MJ, Klatt M. Educational innovations to foster resil- in Learning Mindfulness: Benefits, Paradoxes, and Pitfalls.
ience in the health professions. Med Teach. 2017;39(2):153– Mindfulness (N Y). 2016;7:838–50, https://doi.org/10.1007/
9, https://doi.org/10.1080/0142159X.2016.1248917. s12671-016-0521-0.
38. Saunders PA, Tractenberg RE, Chaterji R, Amri H, Haraz- 46. Turakitwanakan W, Mekseepralard C, Busarakumtragul P.
duk N, Gordon JS, et al. Promoting self-awareness and re- Effects of mindfulness meditation on serum cortisol of medi-
flection through an experiential mind-body skills course for cal students. J Med Assoc Thai. 2013;96 Suppl 1:S90–5.
first year medical students. Med Teach. 2007;29(8):778–84, 47. Chen AK, Kumar A, Haramati A. The effect of Mind Body
https://doi.org/10.1080/01421590701509647. Medicine course on medical student empathy: a pilot study.
39. Dobkin PL, Laliberté V. Being a mindful clinical teacher: can Med Educ Online. 2016;21:31196, https://doi.org/10.3402/
mindfulness enhance education in a clinical setting? Med meo.v21.31196.
Teach. 2014;36(4):347–52, https://doi.org/10.3109/0142159X. 48. Plummer C, Cloyd E, Doersam JK, Dietrich MS, Hande KA.
2014.887834. Mindfulness in a Graduate Nursing Curriculum: A Random-
40. Malpass A, Binnie K, Robson L. Medical Students’ Ex- ized Controlled Study. Holist Nurs Pract. 2018;32(4):189–95,
perience of Mindfulness Training in the UK: well-being, https://doi.org/10.1097/HNP.0000000000000277.
IJOMEH 2021;34(1) 13REVIEW PAPER J. CHMIELEWSKI ET AL.
49. Van Dijk I, Lucassen PL, Speckens AE. Mindfulness training 56. Dyrbye LN, Shanafelt TD, Werner L, Sood A, Satele D,
for medical students in their clinical clerkships: two cross-sec- Wolanskyj AP. The Impact of a Required Longitudinal Stress
tional studies exploring interest and participation. BMC Med Management and Resilience Training Course for First-Year
Educ. 2015;15:24, https://doi.org/10.1186/s12909-015-0302-9. Medical Students. J Gen Intern Med. 2017;32(12):1309–14,
50. Barbosa P, Raymond G, Zlotnick C, Wilk J, Toomey 3rd R, https://doi.org/10.1007/s11606-017-4171-2.
Mitchell 3rd. J. Mindfulness-based stress reduction train- 57. Kuhlmann SM, Huss M, Bürger A, Hammerle F. Coping
ing is associated with greater empathy and reduced anxiety with stress in medical students: results of a randomized
for graduate healthcare students. Educ Health (Abingdon). controlled trial using a mindfulness-based stress preven-
2013;26(1):9–14, https://doi.org/10.4103/1357-6283.112794. tion training (MediMind) in Germany. BMC Med Educ.
51. Van Vliet M, Jong MC, Jong M. A Mind-Body Skills Course 2016;16(1):316, https://doi.org/10.1186/s12909-016-0833-8.
Among Nursing and Medical Students: A Pathway for an 58. Vibe Md, Solhaug I, Rosenvinge JH, Tyssen R, Hanley A,
Improved Perception of Self and the Surrounding World. Garland E. Six-year positive effects of a mindfulness-based
Glob Qual Nurs Res. 2018;5:2333393618805340, https://doi. intervention on mindfulness, coping and well-being in medi-
org/10.1177/2333393618805340. cal and psychology students; Results from a randomized
52. Vibe Md, Solhaug I, Tyssen R, Friborg O, Rosenvinge JH, controlled trial. PLoS One. 2018;13(4):e0196053, https://doi.
Sørlie T, et al. Mindfulness training for stress management: org/10.1371/journal.pone.0196053.
a randomised controlled study of medical and psychol- 59. Phang CK, Mukhtar F, Ibrahim N, Keng SL, Mohd Sidik S.
ogy students. BMC Med Educ. 2013;13:107, https://doi. Effects of a brief mindfulness-based intervention program
org/10.1186/1472-6920-13-107. for stress management among medical students: the Mind-
53. Vibe Md, Solhaug I, Tyssen R, Friborg O, Rosenvinge JH, ful-Gym randomized controlled study. Adv Health Sci Educ
Sørlie T, et al. Does Personality Moderate the Effects of Theory Pract. 2015;20(5):1115–34, https://doi.org/10.1007/
Mindfulness Training for Medical and Psychology Students? s10459-015-9591-3.
Mindfulness (NY). 2015;6(2):281–9, https://doi.org/10.1007/ 60. Gordon JS. Mind-body skills groups for medical students:
s12671-013-0258-y. reducing stress, enhancing commitment, and promoting
54. Nayyar N, Saggio G, Plummer M, Jung MK, Kappenberg J. patient-centered care. BMC Med Educ. 2014;14:198, https://
Association of Mindfulness With Residency Preference doi.org/10.1186/1472-6920-14-198.
and Curriculum Selection in Preclinical Osteopathic Medi- 61. National Institutes of Health, United States National Li-
cal Students. J Am Osteopath Assoc. 2018;118(9):587–95, brary of Medicine Clinical Trials [Internet]. Bethesda: The
https://doi.org/10.7556/jaoa.2018.142. Organization; 2018 [cited 2020 Jul 1]. Mindfulness and Ex-
55. Chung AS, Felber R, Han E, Mathew T, Rebillot K, Lik- ecutive Functions for Prediction of Non-technical Skills of
ourezos A. A Targeted Mindfulness Curriculum for Medical Students in Pediatric Medical Simulations (MindExSim).
Students During Their Emergency Medicine Clerkship Ex- Clinical Trial ID: NCT03761355 (N/ST/ZB/18/002/1206);
perience. West J Emerg Med. 2018;19(4):762–6, https://doi. 2018. Available from: https://clinicaltrials.gov/ct2/show/NCT
org/10.5811/westjem.2018.4.37018. 03761355.
This work is available in Open Access model and licensed under a Creative Commons Attribution-NonCommercial 3.0 Poland License – http://creativecommons.org/
licenses/by-nc/3.0/pl/deed.en.
14 IJOMEH 2021;34(1)You can also read
